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General NPI Number Information
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NPI Number | 1245787506
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Entity Type | Individual
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Provider Name | CAROLINE KELLY TYE LCPC, ATR-BC
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Gender | Female
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Dates
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Enumeration Date | 09/04/2016
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Last Update Date | 11/28/2017
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Provider Practice Location Address
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Address Line | 2630 W FLETCHER ST
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City | CHICAGO
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State | IL
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Zip | 60618-7110
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Country | US
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Telephone | 847-651-8643
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Fax |
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Provider Business Mailing Address
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Address Line | 904 SEWARD ST APT #3
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City | EVANSTON
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State | IL
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Zip | 60202-5321
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Country | US
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Telephone | 847-651-8643
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 221700000X
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Taxonomy Name | Art Therapist
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License Number | 16-069
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178012176
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License Number State | IL
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 180011239
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License Number State | IL
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